Page 264 - Ebook health insurance IC27

The Insurance Times

when insurance crime will be looked upon as 'shameful' or 'criminal' , will the
effort bear some fruits.

(c) Robust Whistle Blow Policy - As a sequel to creating awareness, the insurers
should encourage 'whistle blow policy' or just plain 'squealing' on frauds. This will
not only protect the insurance sector , but also penalize the ones involved in it.

(d) Effective Legislation and Judicial Action - Insurance frauds deserves special
legislation and judicial attention. A few quick, high profile and highly publicized
convictions are probably the strongest medicine for potential fraudsters. Instead
of just repudiating the claims, the frauds should be punished legally and judicially
to drive home the matter.

(e) Fraud Management Philosophy and Policy - Insurance companies should
show ' zero tolerance' towards frauds. Internally, companies should have well laid
out policies to detect, investigate and prevent fraud.

(f) Robust Investigation Unit and Mystery Shopping on Customers - Companies
should create dedicated risk control units who should promptly investigate all
frauds and suspicious transactions discreetly.

(g) Doctor Seeding - This is basically kind of mystery shopping where an Investigator
disguise himself as a patient and tell the doctor to give him a clean chit on the
Medical Examination Form, in spite of suffering from several diseases. Based on
the reactions of the doctor, the actions will be taken on the doctor and all the
cases previously cleared by him will be scrutinized.

(h) Training and Communication - Organizations must adequately invest in creating
sensitivity on this subject. The training and communication should be done as a
part of induction or parts of newsletters and sent to all the stockholders , like
employees, customers, intermediaries, partners and shareholders. Various fraud
scenarios, its prevention and action matrix should be highlighted.

268 Guide for Health Insurance